Basic Information
| Provider Information | |||||||||
| NPI: | 1083935753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALLAHAN | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUCK | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2675 WINKLER AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339019342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15740 NEW HAMPSHIRE CT STE B | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339084174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394668838 | ||||||||
| FaxNumber: | 2394667669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2010 | ||||||||
| LastUpdateDate: | 09/03/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5004708 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | ARNP9448794 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | ARNP9448794 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7000852 | 05 | NC | MEDICAID | 020061900 | 05 | FL | MEDICAID |